Discretion at the margins: An observational study of community pharmacists' adaptive practices in supporting migrant and ethnic minority health

Abstract

Background

Migrants and ethnic minorities (MEM) often face health challenges and structural and social barriers in accessing primary care. Pharmacists, as accessible healthcare professionals with expertise in medication management can address some of these barriers, however, their roles in serving MEM remain underexplored.

Objectives

This study explored the adaptive communication and care practices of community pharmacists in responding to MEM clients in Flanders, Belgium.

Methods

We conducted 42 h of non-participant observation and short reflective consultations with pharmacy staff of seven community pharmacies in two cities during February and March 2025. Field notes were structured using a semi-structured topic guide covering duration and content of pharmacist-client interactions; modes of communication; and delivery of pharmaceutical care. Framework analysis was used to code and categorize field notes according to micro-, meso-, and macro-level factors identified as influencing interactions between pharmacy staff and MEM clients.

Results

Community pharmacy staff bridge healthcare gaps for MEM clients through multiple strategies, shaped by the dual logics of retail and healthcare. They were observed to accommodate diverse languages and proficiency levels; support medication and health (systems) literacy; address socio-economic challenges; and show sensitivity towards socio-cultural dynamics of care-seeking. Reflecting pharmacists' personal and professional motivations, these adaptive practices are shaped by meso-level factors such as staff composition, pharmacy layout, and social norms, as well as pharmacy-level discretionary actions within the Belgian health system and migration policy contexts.

Conclusions

While well positioned to guide MEM clients through a fragmented health system, community pharmacists require systemic policy support to serve diverse population needs effectively.

Highlights

• •Observations reveal pharmacists' care work with migrant and ethnic minority clients.
• •Pharmacists extend roles to address gaps in clients' health and medicines literacy.
• •Adaptive practices reflect individual motivation and discretionary decision-making.
• •Systemic policy support is needed to bolster pharmacists' delivery of equitable care.

1. Introduction

In many countries facing inequalities in access to healthcare and health workforce crises, there has been lively discussion regarding how community pharmacists – often a low-threshold first point of contact with the health system for those with health-related concerns – can respond to the primary care needs of under-served communities,^1,2 including those with a migrant or ethnic minoritized (MEM) background. Based on countries of origin and their migration trajectory, migrants may present with complex health profiles that include different infectious diseases and non-communicable disease co-morbidities; these may be compounded by stress, limited resources, poor living conditions, and disruptions in continuity of care.^3,4 They often face barriers in accessing quality healthcare services in a timely manner due to language barriers, legal status, financial limitations, and the complexity of navigating health systems in a new country.5, 6, 7, 8 Similar obstacles are observed in ethnic minoritized individuals who also experience challenges in healthcare interactions due to language barriers, limited health literacy, and discriminatory attitudes that persist regardless of their settled status.^5,9,10

Enabling community pharmacists to play a more integral role within the network of primary care providers could have a positive impact on health outcomes.¹¹ Given their accessibility, community pharmacists could play a vital role in care coordination, patient navigation, social prescribing or in brokering resources for under-served or marginalized individuals including those with an MEM background.12, 13, 14 Studies from some European countries indicate that they already play this role to an extent: old age, loneliness, long-term care needs, a higher number of medications and a lower level of education have been associated with a higher likelihood of utilizing non-dispensing pharmacy services, seeking cognitive pharmaceutical care and viewing the pharmacy as a central player in the health system.15, 16, 17 However, little is known about the impact of pharmacy-delivered public health interventions on health inequalities¹¹ and how best to deliver pharmacy-based interventions that might address some of the gaps in health care for individuals from minoritized backgrounds.¹⁸

Health systems, policy, and legal contexts as well as professional motivations differ and shape what kinds of pharmacy-based interventions can be delivered – and how - to support these individuals. While some pharmaceutical care interventions have focused on vulnerable individuals including older adults¹⁹ and people using drugs,²⁰ other groups may be more marginalized, and less visible, hence given less priority. There is limited research, particularly in Europe, on MEM individuals' use of community pharmacies, pharmacists' interactions with MEM clients, and pharmacists' roles in supporting MEM health. Studies from the US, Australia, and the UK confirm known health systems barriers faced by MEM in access to pharmaceutical care: limited health literacy, different expectations of health services, and the effects of previous negative experiences, including discrimination, with healthcare services.^6,21,22 Conversely, some studies report on pharmacists' limited knowledge of the unique health conditions and needs of under-served populations including MEM, inadequate training and skills in culturally competent care, insufficient time to address complex information needs, and challenges in communication and gaining trust.^23,24

Alongside reports of the formal gaps in pharmacy care provision for MEM, a growing body of in-depth qualitative research indicates that pharmacists are already quietly engaged in supporting health access and health literacy of MEM individuals. A recent meta-ethnography of 14 qualitative studies identifies four key domains of”culturally-centred pharmacy services” pertinent to the experience of MEM individuals including navigation of pharmacy systems, establishing relationships with pharmacists, addressing language barriers and attentiveness to cultural beliefs and practices that impact on medicine use.¹⁸ Work on the everyday practices and communicative roles of pharmacists in the United Kingdom highlights the hybrid retail–healthcare nature of pharmacies²⁵ and pharmacists' adaptive cross-cultural strategies employed in diverse communities.²⁶ Our study builds on this body of work by providing observational insights into pharmacists' discretionary agency and adaptive practices in serving individuals with a MEM background in Flanders, Belgium.

2. Background

2.1. Pharmacies in Belgium

Community pharmacists' roles and scope of practice differ substantially across Europe, depending on national legal and regulatory frameworks.^27,28 In Belgium, responsibility for health policy—including pharmacy practice—is constitutionally divided between the federal state and federated entities. The federal government retains exclusive control over legislation, registration, pricing of pharmaceuticals, and regulation of health professionals, while the regions and communities (such as Flanders) are responsible for implementation aspects like health promotion, primary care coordination, infrastructure, and quality oversight. This division has given rise to regionally distinctive health and pharmacy practices within the country.^29,30

In Flanders, recent primary care reforms have reorganised services into approximately 60 eerstelijnszones (primary care zones). Pharmacists are partially integrated in these zones through local “pharmacists' circles” (apothekerskringen) that support medication management, interdisciplinary collaboration, and preventive health initiatives at the community level.³¹ These reforms are complemented by broader policy efforts to strengthen the preventive and clinical role of pharmacists, for example by involving them in vaccination campaigns during and after the COVID-19 pandemic and positioning them as key providers of medication counselling and adherence support.^32,33 However, as compared to some of their European counterparts, Belgian community pharmacists are not always included in healthcare reforms, and their potential contributions remain often underused.

2.2. Migrant access to healthcare in Belgium

The Belgian population is becoming increasingly diverse: as of January 1st, 2025, 36% of residents have a foreign background. This group is highly heterogeneous and includes both Belgian nationals with a foreign background and non-Belgian residents, originating from neighbouring countries, other EU member states, and non-EU countries, with substantial representation from North Africa, Turkey, and Sub-Saharan Africa. In Flanders specifically, nearly 28% of the population is of foreign origin, of whom approximately 40% have an EU origin.^34,35 Healthcare access in Belgium is generally good but large disparities exist across socio-economic groups, with significant regional variations in levels of unmet needs and inequalities in access to care. Although the intersection between health and MEM status remains under-documented, analysis of the Belgian Public Health Survey 2018 shows that individuals with a non-EU nationality are significantly less likely to have a family physician and more likely to have never consulted a GP, dentist, or a specialist than the native Belgian population.⁹ Particularly for asylum seekers, data is scarce, but procedures to access healthcare differ by region and are reported to be complex and burdensome.³⁶ An important challenge for health policy is thus to find innovative ways to effectively reach these underserved groups.

3. Aim and objectives

The overarching aim of this observational study was to document pharmacists' communication and care practices with clients of MEM background, particularly in ethnically diverse urban neighbourhoods in Flanders, where linguistic, social or structural barriers are present. We examined the duration and content of interactions between pharmacy staff and clients and modes of communication used in the delivery of pharmaceutical care. Further, we elicited pharmacists' reflections on the challenges and opportunities faced in addressing general health concerns as well as specific issues related to medicines that were expressed by MEM clients. Our intention was to elucidate contextual factors influencing pharmacists' motivation and agency in adapting care practices when serving individuals of MEM background.

4. Methods

4.1. Study design

We conducted a cross-sectional observational study using qualitative methods in seven community pharmacies over a period of two months (February and March 2025). Direct, semi-structured, non-participant observations and short reflective conversations with pharmacy staff were conducted at two separate time slots in each participating pharmacy to capture variations in client flow and pharmacist-client interactions.

4.2. Study setting, sampling and recruitment strategies

Our study was implemented in community pharmacies situated in the cities of Ghent and Antwerp. We purposively selected areas characterized by a higher density of MEM individuals, identified by overlaying publicly available administrative data on nationality, migration and ethnicity of the two cities.^37,38 Local coordinators of pharmacist associations in Flanders acted as study gatekeepers, contacting and informing pharmacy staff in the selected areas about the study, and encouraging their participation. A simple synopsis of the study and a flyer containing the coordinating researchers' contact details was sent out to all potential participants via email; we also canvassed pharmacies in the identified areas in person to distribute the synopsis and flyers.

Pharmacists who expressed interest in the study were contacted via email by the first author with a participant information sheet that described what participation involved, the estimated time commitment, and confidentiality measures. For the pharmacy visits, a short informative visual was developed in A3 poster format for display in the participating pharmacies (Appendix A). All materials were prepared in Dutch, French, and English.

4.3. Ethical considerations

The study was approved by the Institutional Review Board (IRB) of the Institute of Tropical Medicine, Antwerp (Reference number: 1844/25). Lead pharmacists, who acted as gatekeepers for participating pharmacies, were informed of the study objectives and the voluntary nature of participation. Written informed consent was obtained from pharmacists who agreed to take part in the study. To protect the privacy of pharmacy staff and clients, no audio or video recordings were made. Information flyers describing the purpose of the study, the presence of the researcher, measures to protect the confidentiality of information gathered through the observations, and contact details for the researcher were displayed at the entrance and throughout the pharmacy (Appendix A). Given the non-interventional design and the non-participant observation of routine care in a public healthcare setting, individual written consent from clients was not sought, as no personal or identifiable data were collected and no audio or video recordings were made.

We applied specific considerations in our observations to avoid stereotyping individual pharmacy clients or making assumptions regarding MEM background based solely on appearance. Rather, we inferred MEM status from observable markers relevant to the study e.g. language spoken by the client; signs of unfamiliarity with pharmacy or healthcare procedures and prescriptions; and pharmacists' adaptive responses in communication practices.

4.4. Data collection

4.4.1. Observations

Direct, semi-structured, non-participant observation was deemed a relevant method for documenting pharmaceutical care as the method captures real-time interactions and behaviours that may not surface in interviews or survey questionnaires. Observations can provide nuanced insights into the dynamics of pharmacist-client communication, contextual influences on care delivery, and the implicit practices that shape healthcare experiences, as demonstrated in other recent studies.39, 40, 41 Our focus was on pharmaceutical care practices for individuals with a MEM background, specifically the duration and content of patient-pharmacist interactions, and adaptations in communication and delivery of pharmaceutical care (e.g. information, advice, referrals) in addition to dispensing (Appendix B: Semi-structured topic guide).

Observations were conducted by the first author. Training in qualitative methods was supported by co-authors with complementary expertise in community pharmacy practice in Belgium and ethnographic methods as applied within health systems research. We scheduled observations in consultation with the lead pharmacist of participating pharmacies to accommodate their availability, workflows and peak operating hours. Pharmacies were visited on two different days of the week, and at two different times of the day, with the exception of two pharmacies (P1 and P6), that were either visited on the same day, or during the same hours. We adopted the “observation as non-participant observers” role,⁴² to minimize disruption to the pharmacy's daily operations, and impact of the observer on the activities being observed. Observations encompassed all professionals associated with the pharmacy and interacting with clients, including (lead) pharmacists, pharmacy technicians, and pharmacist/pharmacy technicians' trainees. Each observation session lasted between two to three hours. Notes were recorded primarily in textual form and in some cases, supplemented by visual diagrams that, for example, showed the use of space in the pharmacy.

4.4.2. Reflective consultations

During and at the end of each observation, the researcher sought opportune moments to have short reflective consultations with the pharmacy staff; prompts for reflection were included in a short topic guide (Appendix C) that was used flexibly. Participants were encouraged to clarify intentions, to share perspectives, and to provide context for observed interactions. These notes helped us to better understand the rationale underlying observed behaviours and to foster collaborative insights on issues arising, including if what was observed on the day was ‘typical’ or ‘atypical’.

4.5. Data management

Handwritten raw field notes were expanded after the observation sessions to maximize recall, with care taken to differentiate between descriptive and analytical notes. All observation field notes were typed up by the first author, incorporating notes from the reflective consultations. Each interaction between a pharmacy staff member with a client was treated as a potential unit of analysis. In total, we recorded notes on 734 interactions with a median of 107 observations per pharmacy (min-max 66–140) (Table 1). Of these, 579 interactions were excluded from further analysis: we automatically excluded interactions involving Belgian clients of non-MEM backgrounds and further excluded observations of interactions that were incomplete, due to the following reasons: partially or fully obstructed; limited or no communication between the pharmacist and client; communication focused on non-healthcare related content; brevity (under 1 min); and/or inaudible or unintelligible for the observer.

Table 1.

Number of interactions per pharmacy.

Pharmacy	P1	P2	P3	P4	P5	P6	P7
Number of interactions observed	110	66	107	104	136	140	71

The lead author shared typed-up fieldnotes from two contrasting pharmacy settings with the co-authors, who decided which interactions would form the basis of analysis for the paper, following review and annotation of the fieldnotes. For further analysis, 155 interactions were retained, selected to maximize diversity in terms of client gender/sex (female, male), age category (child, young adult, adult, older adult), communication flow (fluid or non-fluid), and whether the client was seeking care for themselves or on behalf of someone else (Table 2).

Table 2.

Micro-level characteristics of selected interactions (n = 155).

Characteristics	Number (percentage)
Gender of client
Female	78 (50.32%)
Male	77 (49.68%)
Age of client
Child (≤12y)	2 (1.29%)
Young person (13-18y)	3 (1.94%)
Adult (18-64y)	137 (88.39%)
Older adult (>65y)	13 (8.39%)
Purpose of visit
Advice only	8 (5.16%)
Purchase only	9 (5.81%)
Advice + purchase	138 (89.03%)
Primary beneficiary of visit
Self-initiated	110 (70.97%)
On behalf of other	45 (29.03%)
Type of purchase
Non-drug	44 (28.39%)
Prescription drug	79 (50.97%)
OTC drug	50 (32.26%)
Method of payment
No payment	26 (16.77%)
With card	86 (55.48%)
With cash	43 (27.74%)

4.6. Data analysis

The first author read all fieldnotes from the 155 interactions and shared a selection of these with the co-authors to review and annotate. Preliminary classification of macro-, meso-, and micro-level dimensions of pharmacy practice were aligned with the topic guide and served as the basis for framework analysis. Two meetings were held with the co-authors to discuss the emerging themes and to prompt critical reflection on how context shaped meaning and agency in the interactions observed. Through iterative readings and preliminary annotation of the transcripts, we reached a consensus on the macro-, meso-and micro-level factors influencing the duration, content, and communication practices in the observed interactions (Appendix D: Macro-, meso-, and micro-level themes). In line with framework analysis, we used these themes to develop a data matrix that enabled us to categorize extracts from the observation and reflective notes and to compare and contrast common factors influencing interactions as well as outliers, i.e. interactions that did not fit commonly seen patterns.⁴³

5. Results

5.1. Profile of participating pharmacies and interactions observed

Five of the participating pharmacies were located in Antwerp and two in Ghent. Two were smaller pharmacies, three were medium-sized and two were larger pharmacies. We based the assessment of size on our observation of the available space in the pharmacy, the number of employees, and the number of clients attending the pharmacy. We observed mainly pharmacists (n = 20), and a small number of pharmacy technicians (n = 3), and pharmacist / pharmacy technician trainees (n = 5) (Table 3).

Table 3.

Profile of pharmacies and pharmacy staffing.

Pharmacy observed		Pharmacy staff observed				Number and percentage of interactions included for further analysis
ID	Size	Staff (n)	Gender (F/M)	Ethnicity (non-MEM/ MEM)	Type of staff (Pharm. / P. Tech. / Tr. Pharm. / Tr. P. Tech.)
PH-1	Medium	2	2 / 0	1 / 1	1 / 1 / 0 / 0	20 (12.90%)
PH-2	Medium	4	4 / 0	4 / 0	4 / 0 / 0 / 0	18 (11.61%)
PH-3	Small	3	3 / 0	3 / 0	2 / 1 / 0 / 0	31 (20.00%)
PH-4	Large	5	4 / 1	2 / 3	4 / 0 / 1 / 0	14 (9.03%)
PH-5	Large	6	4 / 2	5 / 1	5 / 0 / 1 / 0	28 (18.06%)
PH-6	Medium	5	3 / 2	3 / 2	2 / 1 / 1 / 1	28 (18.06%)
PH-7	Small	3	2 / 1	3 / 0	2 / 0 / 1 / 0	16 (10.32%)

Pharm. = Pharmacist; P. Tech. = Pharmacy Technician; Tr. Pharm. = Trainee Pharmacist; Tr. P. Tech. = Trainee Pharmacy Technician.

5.2. A day in the life of Pharmacy X

Situated in a linguistically diverse urban area, this pharmacy serves a clientele for whom Dutch is often not a first language. Pharmacy staff frequently encounter challenges stemming from language differences, limited health literacy and unfamiliarity with the Belgian health system. They routinely supplement spoken Dutch with English and French, gestures, and written notes, and rely on intermediaries, including children and adolescents, who step in on behalf of relatives lacking the language skills, confidence, or mobility to visit the pharmacy. Clients often make use of their mobile phones to translate their requests, show a desired brand of medication, or to consult with a relative. Several clients decline prescribed medications, citing costs, unfamiliarity, or mistrust regarding generic medication. Pharmacy staff provide first-hand health-related advice, at times filling in gaps in understanding incurred with other health providers; they also field many non-health related queries related to daily life. Communication strategies are improvised and situational; in many cases, understanding remains uncertain and partial despite best efforts.

The vignette above highlights routine issues arising in the micro-level interactions between pharmacy staff and clients across the seven pharmacies. Both process and content of pharmacy staff members' adaptive practices were influenced by meso-level factors related to the pharmacies (e.g. organization of care, infrastructure and size, staffing etc.) and client backgrounds (family dynamics, health care related expectations, socio-cultural norms). At the same time, observed interactions must be situated within macro-level systemic factors (e.g. reimbursement system, availability of GPs, location and roles of pharmacies) and specific policies regarding access to healthcare and social support for migrants in Belgium. Four types of adaptive practice were identified: first, adapting communication to respond to the linguistic diversity and proficiency level of spoken Dutch; second, addressing gaps in the health (systems) and medication literacy of clients; third, responding to clients' socio-economic and financial circumstances and fourth, showing sensitivity towards socio-cultural dynamics of care-seeking. We discuss each in turn, with supporting evidence for this analysis provided in Supplemental File 1.

5.3. Adapting to linguistic diversity

A woman, 50 to 60 years old and wearing a hijab, enters the pharmacy accompanied by her son, in his late twenties. The son hands over her ID card to P2 and asks several questions in broken Dutch about her medication. P2 explains the indication for the medication and provides instructions on how to take it. The son translates for his mother [in Arabic?], explaining to P2 that his mother drinks too little water and asking whether the medication is suitable for her. P2 confirms and provides further instructions. The woman mumbles something, and the son says that she does not want the medication. P2 responds that the doctor had recommended a different medication; the son replies that the doctor had not explained this to them. P2 provides additional instructions and asks about the woman's level of discomfort. The son translates again, asking whether his mother should continue taking the medication and whether it always requires a prescription, which P2 confirms (PH-7).

Although Dutch was the main language spoken during the observed interactions, pharmacy staff demonstrated high linguistic adaptability to ensure effective communication with clients, frequently switching from Dutch to other languages. While French and English were the most common alternate languages, staff with a MEM background regularly utilized additional languages. At PH-1, a staff member fluent in Yiddish and Hebrew supported communication with the local Jewish community. PH-4 had an exceptionally diverse team with staff members of Belgian, Russian, Polish, Dominican Republic, Moroccan, and Syrian backgrounds. At PH-5, staff with Berber language skills facilitated communication with clients of Berber origin. Similarly, staff at PH-6 who were fluent in Arabic helped bridge language barriers for Arabic-speaking clients. The three pharmacies (PH-2, PH-3, PH-7) that did not have staff from MEM backgrounds relied on Dutch, French, and English, which sometimes limited their ability to engage with MEM clients. Lead pharmacists held diverging opinions with respect to multilingual pharmacy staff: some viewed the presence of MEM staff members or multilingual abilities as an asset while others felt it was neither feasible nor realistic to expect every pharmacy to employ multi-lingual staff, further arguing that Dutch should remain the primary language used.

In addition to switching languages, pharmacy staff often adjusted the complexity of their spoken language by using simplified syntax, avoiding technical or medical jargon, and providing shorter instructions for medicines intake, dosing, and duration. However, these supportive communication practices were not applied consistently. Not all pharmacy staff adjusted their language, and we observed numerous cases where clients seemed not to fully grasp the advice provided. During reflective consultations, some staff members acknowledged this uncertainty, noting that time pressures, or lack of clear feedback from clients hindered effective communication.

All pharmacy staff regularly used hand gestures, body language, facial expressions, and physical demonstrations to clarify dosage instructions or explain the use of medical devices. They were attentive to clients' non-verbal cues, such as pointing to specific body parts or mimicking symptoms, to better understand health complaints or determine the medication needed. Additionally, they used tools, such as Google Translate, DeepL, visual instruction sheets or videos, to support verbal communication, occasionally encountering limitations related to the accuracy of automated translations.

5.4. Bridging gaps in medication and health (systems) literacy

An elderly woman approaches S2, handing over a piece of paper. S2 retrieves the prescribed medication, but the woman explains in broken Dutch that she does not need it and is currently experiencing pain, pointing to her ribs. S2 explains that the doctor had prescribed it, but the woman interrupts repeatedly with “no, no, no,” resisting the suggestion. S2 clarifies that the doctor recommended both physiotherapy and this medication. The woman remains adamant that she does not want to take it and leaves the pharmacy without purchasing the medication. (PH-6).

Recurrent challenges noted in every pharmacy were clients' knowledge gaps regarding their medication and more generally, understanding of the health system. Pharmacy staff often played an active role in supporting clients' health and medicines literacy, taking additional time to explain the indication and use of prescribed medications or medical devices, repeating instructions and responding to verbal and non-verbal cues that signalled confusion or misunderstanding. However, this level of support was not consistent across all cases. Pharmacy staff highlighted that time constraints and clients' reluctance to engage with explanations sometimes limited the extent of counselling.

In all pharmacies, visited, staff frequently had to explain the difference between generic and branded medications, particularly when clients expressed concerns about receiving a product that looked different from what they expected. They noted that some clients preferred branded drugs due to symbolic value, perceived quality differences, or mistrust in generics. In many interactions observed, they explained the equivalence of active ingredients, safety, efficacy, and price while clarifying why a generic alternative might be dispensed.

Furthermore, all pharmacies frequently encountered clients searching for medications, supplements or (health) products that were available in their countries of origin but not registered or sold in Belgium. In some cases, clients brought packaging or photos from abroad to clarify what they were looking for. Staff members expressed challenges in identifying these products and in providing suitable alternatives that complied with Belgian pharmaceutical regulations.

Pharmacy staff were also observed to temper clients' expectations regarding the delivery of pharmaceutical care. For example, in interactions with clients used to being able to obtain medications immediately or without a prescription in their countries of origin, pharmacists clarified the constraints of stock availability, estimated preparation or waiting times, or the need to order certain medications or products. Recognising clients' unfamiliarity with the Belgian health system and its procedural requirements, many took pains to explain the health insurance system, prescription procedures, and the referral process. Handling cases of missing or incorrect prescriptions was a common challenge and required active problem-solving, such as contacting the prescriber, clarifying treatment intentions, or providing clients with instructions on how to obtain a valid prescription. Many clients arrived with paper-based prescriptions, some of which were no longer valid. The reliance on paper prescriptions in the era of electronic ID-linked prescribing systems highlights the digital divide affecting some clients.

Pharmacy staff across sites perceived that communication with the prescribing physician, more specifically medical specialists, was one of the weakest links in the healthcare chain. While contact with general practitioners was generally described as good, reaching specialists proved far more difficult for pharmacists and clients. Staff thus took on the responsibility of reaching out to physicians when faced with incorrect dosages, contradictory prescriptions, or missing details. They also acted as informal medical advisors, not only when clients lacked guidance from other healthcare providers, but also in instances where clients were entirely unable to access a health provider. Serving as a first point of contact for health-related inquiries, symptom assessment, and medication management, some further directly observed medication intake to ensure adherence and correct use, specifically with clients with complex treatment regimens or those perceived to be at risk of poor adherence.

In other instances, pharmacies appeared to be the first point of contact in health-seeking. This frontline role was particularly notable in the context of sexual health concerns: several young men approached the pharmacy seeking advice or OTC treatment related to sexual health matters. Beyond medical matters, pharmacy staff often assisted clients with practical, non-healthcare related inquiries, offering answers to everyday queries such as finding a locksmith, or the opening hours of a hairdresser.

5.5. Responsiveness towards socio-economic and financial circumstances

An elderly man enters the pharmacy explaining that he has just returned from Africa and needs diabetes medication. P1, speaking mainly in Dutch and using expressive body language, informs him that his previous prescription has expired and advises him to consult a doctor. The man appears confused and repeats his request. Eventually, P1 agrees to provide a small supply, explaining in a mix of Dutch and English how to take it, while emphasizing that a new prescription is still required. When the man attempts to pay with foreign currency and says he has left his bank card abroad, P1 retrieves the original medication box and gives him a few blister packs free of charge, again stressing the need to see a doctor. (PH-6).

Pharmacy staff showed awareness of their clients' occasionally challenging financial situations, initiating conversations about medication costs and offering lower-cost alternatives when appropriate. In some cases, clients requested cash when paying by card: some pharmacists declined due to the high volume of such demands, while others accepted, noting that a significant portion of their clientele paid in cash and they therefore had sufficient cash available. Additionally, pharmacy staff frequently assumed an advisory role in addressing clients' misunderstandings and uncertainties about medication reimbursement. The Belgian reimbursement system is complex, involving multiple layers of regulations, and varying reimbursement percentages depending on the type of medication, the client's health insurance status, and individual circumstances such as income level. Many clients were confused about which medications were reimbursed, the amount they were expected to pay out-of-pocket, and the procedures for receiving reimbursements. Pharmacists in PH-2 observed a decrease in client visits towards the end of each month, a pattern reflecting the monthly ceiling of the Belgian governmental financial assistance towards medication costs for vulnerable groups. Clients who reach this financial threshold must cover the cost of any additional medications themselves, leading many to postpone non-urgent purchases until the subsidy resets in the following month.

Pharmacy staff frequently took back unopened boxes of medication, particularly those provided free of charge or at a very low cost through the health system. During reflective consultations, some expressed concerns, noting that unused medication returns might indicate non-adherence, overuse of medication, or misunderstandings about the treatment regimen.

5.6. Sensitivity towards socio-cultural and familial dynamics of care

A man in his early thirties enters the pharmacy sniffling and says in broken Dutch “I need something for a sore throat”. P1 asks if it is for himself and whether he has a dry or productive cough, demonstrating making a dry cough sound and then a “Chhh chhh” sound. P1 asks if he has taken anything for his cough before. The man explains what he has taken, which turns out to be for the wrong type of cough. P1 suggests a medication to be taken twice daily during the day. The man replies, ‘You see, now Ramadan’. P1 apologizes, and says, ‘Excuse me, if you eat and then sleep, it's not good. I will find another one’. P1 proposes another medication that can be taken once a day and emphasizes the importance of drinking plenty of water. (PH-3).

Pharmacy environments demonstrated varying levels of sensitivity towards socio-cultural norms in their efforts to facilitate communication with MEM clients. Some pharmacies offered multi-lingual informational materials, most commonly in Dutch, French, and English. Signage practices differed: PH-2 used pictograms to support clients with limited literacy or language proficiency, while others (PH-2, PH-4, PH-7) displayed shelf titles only in Dutch or without any explanatory labelling (PH-1, PH-3, PH-5, PH-6). Posters in PH-2 provided information about whether certain dietary supplements contained gelatine, reflecting an awareness of religious dietary restrictions. However, such explicit visual cues were absent in other pharmacies observed. Across multiple pharmacies, staff responded to questions about the presence of alcohol or pork-derived gelatine in medications and supplements. All pharmacies employed TV screens displaying medication advertisements; more interactive electronic touchscreens were present in PH-3 and PH-5. Staff at PH-1 queried the cultural appropriateness and accessibility of electronic screens for their clients, suggesting that they might find screens confusing or impersonal.

During the observation period, Ramadan was ongoing. Pharmacy staff adapted their medication counselling to accommodate fasting schedules, often inquiring whether clients were observing Ramadan and discussing possible adjustments to medication timing. When clients themselves raised the topic, staff explored feasible intake schedules that respected both medical needs and religious obligations. In addition to Ramadan, staff in PH-1 and PH-4 noted Jewish Passover as another period requiring specific attention. In preparation for the holiday, many clients returned products including medications, food supplements, and creams, that do not meet kosher requirements. After Passover, these pharmacies typically saw a noticeable increase in purchases, as clients restock with items that meet religious and dietary requirements.

Pharmacy staff responded to the familial dynamics of care-seeking by interacting directly with relatives, often adolescents and children, who visited the pharmacy to collect medication on behalf of adult family members and acted as interpreters. They also regularly interacted with adult family members who accompanied or represented elderly relatives with limited language proficiency or health literacy, collecting medication on their behalf and providing context for the patient's condition or treatment history. In reflective conversations, pharmacy staff noted that relying on informal interpreters might compromise the accuracy of medical information and complicate their ability to assess understanding or adherence.

6. Discussion

This exploratory observational study provides new insights into how pharmacy staff engage with and respond to clients of migrant and ethnic minority (MEM) backgrounds in ethnically diverse urban neighbourhoods in two cities in Flanders, Belgium. Our findings contribute to a small but growing body of research highlighting the role of community pharmacists as a first point of contact for health-related concerns among MEM individuals, who may face linguistic, social, or structural barriers in accessing mainstream healthcare services.6, 7, 8^,21 We observed several communication and care challenges in interactions between pharmacy staff and MEM clients, yet also noted the humanizing potential of pharmacist–client communication⁴⁴ and the value of relational continuity in knowing clients as individuals,⁴⁵ particularly poignant for MEM individuals who may be far from ‘home’.

The adaptive practices we documented – both problematic and promising – were largely shaped by individual motivation, personal biases, and the capacity of staff to exercise agency within a highly regulated healthcare setting. In Western European countries including Belgium, community pharmacists operate within a tightly controlled policy and reimbursement framework that leaves limited formal space for tailored or flexible service provision. Yet, our findings show that staff frequently apply discretionary decision-making, that is, they interpret and adapt policies and professional norms in situ to respond to clients' complex and context-specific needs. This discretionary space becomes a critical site for staff to navigate tensions between regulatory compliance and equitable care delivery. Whilst communication in medical consultations is frequently characterized by professional authority and asymmetry⁴⁶ community pharmacy encounters are shaped by the dual logics of retail and healthcare. This ambiguity may represent a source of professional tension^25,26 but also creates space for more flexible and negotiated forms of communication, in which clients may actively request, question, or decline advice. As observed in our study, this flexibility is particularly relevant in pharmacies serving diverse populations, where adaptive practices in language use, expectation management, and socio-cultural responsiveness are essential to mediating access to care. We identified four key types of adaptive practices that staff used in response to MEM clients' needs: language and communication adaptations, support for health and medicines literacy, socio-economic responsiveness, and socio-cultural sensitivity.

Community pharmacies operate at the edge of the health system, serving as a linguistically, culturally, and institutionally mediated translation zone for clients with complex or fragmented narratives of illness and medication use. In line with existing literature on health care access among MEM populations, language remains one of the most significant barriers to the effective use of pharmacy services.^6,21,22,47, 48., 49 Clients with limited proficiency in Dutch, French, or English often struggled to express their needs or to comprehend medication instructions; in many instances, pharmacists in our study used non-verbal strategies, including visual aids and written information, to support bridge communication gaps. Age further shaped these interactions: older adults faced additional challenges due to limited language skills or cognitive decline, prompting pharmacy staff to simplify their communication. Similar findings were noted in a study undertaken among elderly migrant pharmacy clients in Denmark prompting the authors to recommend tailored communication strategies for this group.⁵⁰ These findings underscore the pharmacy as a negotiated communicative space, where language work is not just functional but constitutive of care itself, occasionally blurring the boundaries between clinical advice and everyday mediation.

The organization of care and the physical infrastructure of the pharmacy further influenced what kind of relational work could be enacted. For instance, staff composition and background had an impact on the navigation of linguistic and cultural barriers. Pharmacies with diverse multi-lingual teams (PH-1, PH-4, PH-5, PH-6) were able to engage with clients in their preferred language, fostering relational trust, as observed in a study from Germany.⁸ Yet some pharmacists emphasized practical and ideological reservations on hiring based on language skills, citing resource constraints, staffing shortages, and the conviction that Dutch should remain the default language of professional interactions. While bi- or multi-lingual healthcare professionals can enhance the quality of health for MEM patients, a Danish study of community pharmacists of MEM origin highlights the potential challenge of balancing personal affiliation with clients and professional boundaries.⁵¹ Technological infrastructure introduced a further layer of complexity in communication of information: interactive electronic screens in some pharmacies (PH-3, PH-5) were used to display and compare products but were not always appropriate, particularly for older or digitally excluded populations, highlighting the irreplaceable value of human mediation.

Language barriers intersected with low medication and health (systems) literacy, further complicating treatment comprehension, and potentially impacting on the course of treatment.^8,18,52,53 Pharmacy staff partly compensated for these limitations by providing extended verbal explanation, and clarifying confusion, e.g. regarding generic and branded medication or differences in products and their packaging in Belgium and countries of origin.

Functioning at the frontline of care, pharmacy staff frequently took on informal advisory and stop-gap roles, elucidating prescription systems and reimbursement processes, following up on missed or expired prescriptions, and addressing clients' sensitive (sexual) health concerns, complex regimens, or lacking formal entitlements to healthcare. Compared to the traditionally more hierarchical consultation with a physician, pharmacy interactions are often more flexible and pragmatic in guiding clients through bureaucratic landscapes. In this setting, pharmacies function not only as sites of medicine dispensing but also as impromptu brokers of system access. However, this ‘brokering’ support was inconsistently applied and frequently constrained by time pressure or client disengagement. Structurally, Belgian pharmacy staff are reimbursed primarily for dispensing rather than for counselling, with a fixed economic margin and a small counselling component for prescription drugs.⁵⁴ For OTC products, reimbursement is solely product-based; consequently, no formal reimbursement is available for the advisory support pharmacy staff provide, despite any additional time and effort required. The availability and accessibility of general practitioners further shape the role of the pharmacy. In areas with limited availability or access to general practitioners, community pharmacies often become the first and most accessible point of contact for health-related concerns,^55,56 raising expectations placed on pharmacy staff and increasing the frequency and complexity of client queries, particularly for individuals who have limited access to healthcare. Our observations of pharmacists negotiating patients' expectations around medicines resonate with a study from the UK, describing”discursive complexity” in the pharmacy space²⁵: pharmacy counter assistants have transformative roles, often shifting the dialogue with customers away from ‘ordinary’ retail encounters onto medical or risk assessment territory. Pharmacists in our study were similarly observed to reframe interactions from commercial to therapeutic discourses when clients brought different expectations of medicines based on prior health system experiences.

Our study shows that cultural and religious proscriptions impacted pharmaceutical interactions to some extent, however the lack of a uniform approach to these norms suggests that Flemish pharmacies have yet to fully integrate cultural awareness into routine medication counselling. This resonates with studies from the United Kingdom²⁶ and Germany,⁸ where socio-cultural responsiveness emerges not as a formalized competence but as an adaptive, everyday strategy through which pharmacists seek to maintain communication and rapport with MEM clients in diverse urban communities. In our study, the observed adaptations to accommodate Ramadan depended largely on individual staff motivation, revealing the absence of formal guidelines or training to support culturally sensitive care consistently.

Finally, we observed that interactions were often indirect, involving family members, with children or adolescents at times assuming the role of informal interpreters. While presenting a practical strategy for pharmacists, this situation raises concerns, as young interpreters may lack the maturity or vocabulary to accurately convey (medical) information, increasing the risk of errors. In addition to exposing minors to potentially distressing information, especially when dealing with complex or sensitive issues,⁵⁷ their involvement might compromise privacy and confidentiality of client data.

Our observations are relevant beyond Flanders. In pluri-diverse contexts like the setting we describe, there is a need to advance the structural integration of pharmacy staff within primary care, recognising and valuing their role in supporting underserved groups including individuals with an MEM background. Pharmacy staff will require training that enhances their capacity to deliver culturally tailored, responsive care in a consistent manner. First, pharmacy education needs to move beyond technical competence towards systematic integration of cultural humility, intercultural communication, and attention to social determinants of health. This aligns with growing calls across Europe and globally for pharmacists to be trained as patient-centred, socially responsive health professionals integrated within primary care networks rather than primarily dispensers of medicines.^27,28,58

Second, professional bodies and continuing education providers should offer practical tools that support inclusive practice, such as structured guidance for working with interpreters, resources for low-literacy communication, and opportunities for reflective learning on bias and stigma. International organisations such as the International Pharmaceutical Federation and WHO have explicitly highlighted the need to strengthen pharmacists' competencies in communication, equity and community engagement,⁵⁹ yet implementation at practice level remains uneven.

Third, policy frameworks must better recognise the time and relational work required for equitable pharmaceutical care. In studies of pharmacy clinical service implementation, traditional payment methods that emphasize dispensing fees have been recognised as a barrier to the uptake of expanded clinical and population health services.⁶⁰ Across Europe, ongoing debates about the expanded role of community pharmacists., including their contribution to prevention, chronic care management and health system navigation, have not yet been matched by reimbursement models that support inclusive care with underserved social groups.⁶¹

7. Strengths and limitations

This qualitative study generated ample contextual insights on an under-researched area in social studies of community pharmacy practice in Europe, namely the everyday interactions between pharmacy staff and clients of a MEM background. Our observations in seven pharmacies across two Belgian cities generated sufficiently rich data to develop robust themes addressing the research aim. We note that some adaptive practices described may well reflect broader characteristics of pharmacy practice in neighbourhoods with higher levels of socio-economic deprivation. However, our observations of interactions with MEM clients are supported by the reflective conversations during which pharmacy staff confirmed specific challenges with language and health system literacy encountered when responding to clients with an MEM background.

Additionally, the participating pharmacy staff volunteered to be observed, which may indicate a higher level of professional engagement or stronger counselling practices compared to pharmacies that declined participation. We also note that the presence of the observer may have influenced the behaviour of those being observed. Although the observations were non-participatory by design, the need for the researcher to remain close to the interactions might have disrupted the natural dynamics between pharmacy staff and clients. To mitigate this potential disruption, reflective conversations were held with the pharmacy staff, providing opportunity to contextualize the observations. The second round of observations conducted also helped to build rapport and reduce any anxiety related to the presence of the researcher.

Lastly, the study relied on a single researcher to conduct observations and record field notes. While this ensured consistency in data collection, it may have limited the range of perspectives captured and introduced interpretative bias. The researcher's positionality, as a young, white researcher with experience of seeking care as a Belgian national, yet without specific experience of pharmacy practice, may have shaped both what was attended to during observations and how interactions were interpreted. Reflexive practice, including the consultations with pharmacy staff, and regular discussion within the multidisciplinary research team, were used to critically reflect on these influences and mitigate potential bias.

8. Conclusion

In our study, community pharmacists took on roles of both gatekeepers and guides in a health system where many clients do not speak the dominant societal language and have limited understanding of how the health system works and their access and entitlements to medicines. These frontline professionals operate in a hybrid space and routinely adapt communication, provide informal counselling, and bridge gaps in care, particularly for clients with a MEM background.

The adaptive practices we have described have been documented in community pharmacies serving culturally and linguistically diverse populations across Europe and elsewhere. While individual motivation to respond to specific linguistic and literacy needs of MEM is laudable, structural support is required if community pharmacists are to contribute meaningfully to equitable care for MEM clients. Moving towards effective and sustainable pharmacy-based strategies that respond to the complex needs of diverse under-served groups will require active buy-in and involvement of pharmacy staff in the design of tailored interventions, as well as systemic and policy support to strengthen and validate the position of community pharmacies in primary care.

Future research should move beyond documenting barriers to examining which educational, organisational and policy-level interventions make a difference for MEM clients' experiences of pharmacy care and care-related outcomes. Importantly, this work must centre MEM perspectives, to ensure that emerging models of community pharmacy care are not only accessible but genuinely responsive to diverse needs.

Funding

This work was supported by the Institute of Tropical Medicine Antwerp (Reference number: 1844/25).

CRediT authorship contribution statement

Charlotte Sente: Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Veerle Foulon: Writing – review & editing, Visualization, Supervision, Methodology, Formal analysis, Conceptualization. Karina Kielmann: Writing – review & editing, Writing – original draft, Validation, Supervision, Resources, Project administration, Methodology, Funding acquisition, Formal analysis, Conceptualization.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the authors used ChatGPT and CoPilot in order to check grammar and improve readability, as the first author is not a native English speaker. The authors reviewed and edited the content as appropriate and take full responsibility for the content of the publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

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